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INCOME DECLARATION
FORM
(Self Attested)

I S/D/o Sh.

Father/Mother/Guardian of R/o

Tehsil District

State do hereby solemnly state and affirm as under: -

1. That I am a citizen of India and permanent resident of address mentioned above.

2. That my ward (Son / Daughter) (Name of the student) bearing Provisional Reg.

No. would like to apply for LPU based Scholarship Scheme for the session

3. That my and my family annual income from all sources is mentioned below:

#
Annual Income from
Family Details Education Level Occupation
all sources (in Rs.)

Father

Mother

Guardian (To be filled only if he/she

is paying the fees of the ward)

#
Total annual family income from all sources (in Rs.)

#
Income from salary/ pension/ rental/ business/ profession/ agriculture /any other sources.

I hereby declare that all the information either mentioned above or in enclosed documents (if any) are true and correct to the best of my
knowledge and nothing has been concealed therein. I very well know the fact that if any information is found to be false and incorrect
than I will liable to be punished under Law in Force and any benefits received by me will be liable to be ceased.

Self Declare
(Signature of Parents/ Guardian* with date)
In case Father is not alive, then certificate from Mother / Guardian is required
Mention relation with applicant in case of Guardian
*Signature must be same as on application form for admissions